Difference In Rate Of Surgical Site Infection Research Articles

Post-operative antibiotic prophylaxis in spine surgery patients with thoracolumbar drains: A meta analysis

Closed-suction drains are commonly placed after thoracolumbar surgery to reduce the risk of post-operative hematoma and neurologic deterioration, and may stay in place for a longer period of time if output remains high. Prolonged maintenance of surgical site drains, however, is associated with an increased risk of surgical site infection (SSI). The present study aims to examine the literature regarding extended duration (≥24h) prophylactic antibiotic use in patients undergoing posterior thoracolumbar surgery with closed-suction drainage. This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting the use of 24-h post-operative antibiotics compared with extended duration post-operative antibiotics in patients undergoing posterior thoracolumbar surgery with closed-suction drainage were identified from a PubMed database query. Six studies were included for statistical analysis, encompassing 1003 patients that received 24h of post-operative antibiotics and 984 patients that received ≥24h of post-operative antibiotics. The SSI rate was 5.16% for the shorter duration group (24h) and 4.44% (p=0.7865) for the longer duration group (≥24h). There is no significant difference in rates of SSI in patients receiving 24h of post-operative antibiotics compared with patients receiving ≥24h of post-operative antibiotics. Shorter durations of post-operative antibiotics in patients with thoracolumbar drains have similar outcomes compared to patients receiving longer courses of antibiotics. Shorter durations of antibiotics could potentially help lead to lower overall cost and length of stay for these patients.

Differences in microorganisms causing infection after cranial and spinal surgeries.

The primary aim of this retrospective study was to assess differences in the pathogens causing surgical site infections (SSIs) following craniectomies/craniotomies and open spinal surgery. The secondary aim was to assess differences in rates of SSI among these operative procedures. ANOVA tests with Bonferroni correction and incidence risk ratios (RRs) were used to identify differences in pathogens by surgical site and procedure using retrospective, de-identified records of 19,993 postneurosurgical patients treated between 2007 and 2020. The overall infection rates for craniotomy/craniectomy, laminectomy, and fusion were 2.1%, 1.1%, and 1.5%, respectively, and overall infection rates for cervical, thoracic, and lumbar spine surgery were 0.3%, 1.6%, and 1.9%, respectively. Craniotomy/craniectomy was more likely to result in an SSI than spine surgery (RR 1.8, 95% CI 1.4-2.2, p < 0.0001). Cutibacterium acnes (RR 24.2, 95% CI 7.3-80.0, p < 0.0001); coagulase-negative staphylococci (CoNS) (methicillin-susceptible CoNS: RR 2.9, 95% CI 1.6-5.4, p = 0.0006; methicillin-resistant CoNS: RR 5.6, 95% CI 1.4-22.3, p = 0.02); Klebsiella aerogenes (RR 6.5, 95% CI 1.7-25.1, p = 0.0003); Serratia marcescens (RR 2.4, 95% CI 1.1-7.1, p = 0.01); Enterobacter cloacae (RR 3.1, 95% CI 1.2-8.1, p = 0.02); and Candida albicans (RR 3.9, 95% CI 1.2-12.3, p = 0.02) were more commonly associated with craniotomy/craniectomy cases than fusion or laminectomy SSIs. Pseudomonas aeruginosa was more commonly associated with fusion SSIs than craniotomy SSIs (RR 4.4, 95% CI 1.3-14.8, p = 0.02), whereas Escherichia coli was nonsignificantly associated with fusion SSIs compared to craniotomy SSIs (RR 4.1, 95% CI 0.9-18.1, p = 0.06). Infections with E. coli and P. aeruginosa occurred primarily in the lumbar spine (p = 0.0003 and p = 0.0001, respectively). SSIs due to typical gastrointestinal or genitourinary gram-negative bacteria occur most commonly following lumbar surgery, particularly fusion, and are likely to be due to contamination of the surgical bed with microbial flora in the perianal area and genitourinary tract. Cutibacterium acnes in the skin flora of the head and neck increases risk of infection due to this microbe following surgical interventions in these body sites. The types of gram-negative bacteria associated with craniotomy/craniectomy SSIs suggest potential environmental sources of these pathogens. Based on the authors' findings, neurosurgeons should consider using a two-step skin preparation with benzoyl peroxide, in addition to a standard antiseptic such as alcoholic chlorhexidine for cranial, cervical, and upper thoracic surgeries. Additionally, broader gram-negative bacterial coverage, such as use of a third-generation cephalosporin, should be considered for lumbar/lumbosacral fusion surgical antibiotic prophylaxis.

Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty.

Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Outcomes of Two Different Negative Pressure Therapy Systems for Closed Incision Management in Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis.

Closed incision negative pressure therapy (ciNPT) has been adopted into practices of diverse surgical specialties to help reduce postsurgical complication risks. There are two primary commercially available systems that deliver ciNPT through different mechanisms. The purpose of this meta-analysis is to compare the potential effects of two different ciNPT systems on clinical outcomes following hip and knee arthroplasty. A systematic literature search was conducted to identify hip and knee arthroplasty studies comparing the incidence of surgical site infections (SSIs) and surgical site complications (SSCs) versus standard of care (SOC) following the use of two different ciNPT systems. Four meta-analyses were performed by calculating risk ratios (RR) to assess the effect of (1) ciNPT with foam dressing (ciNPT-F) versus SOC and (2) ciNPT with multilayer absorbent dressing (ciNPT-MLA) versus SOC. Comprehensive Meta-Analysis Version 3.0 (Biostat Inc., Englewood, NJ) software was used to perform the analyses. Twelve studies comparing ciNPT-F to SOC and six studies comparing ciNPT-MLAto SOC were analyzed. SSI rates were reported in seven of 12 studies involving ciNPT-F. In those, ciNPT-F significantly reduced the incidence of SSI (RR = .401, 95% confidence interval (CI) = .190, .844; p = .016). Across four of six studies that reported SSI rates, there was no significant difference in SSI rates between ciNPT-MLAvs SOC (RR = .580, 95% CI = .222, 1.513; p = .265). SSC rates were evaluated in eight of 12 ciNPT-F studies that reported SSC rates. This meta-analysis of the eight ciNPT-F studies showed significantly reduced SSC rates with ciNPT-F vs SOC (RR = .332, 95% CI = .236, .467; p < 0.001). For ciNPT-MLA, five of six studies reported SSC rates. In those, there was no significant difference in SSC rates between ciNPT-MLA vs SOC (RR = .798, 95% CI = .458, 1.398; p = .425). These meta-analyses results showed a significant reduction in SSI and SSC rates in the ciNPT-F group vs SOC and no difference in SSI and SSC rates in the ciNPT-MLA group vs SOC. The reasons for these observed differences were not evaluated as part of this study.Future controlled clinical studies comparing outcomes between different ciNPT systems over closed orthopedic incisions would help to validate these study results.

Postoperative Antibiotics Following Reduction Mammaplasty Does Not Reduce Rates of Surgical Site Infection.

The efficacy of antibiotic utilization following reduction mammaplasty has not been well studied. Furthermore, there is a lack of data describing subgroups who are historically at high risk for surgical site infection (SSI), specifically the obese population. This study compares SSI rates in reduction mammaplasty patients who received postoperative courses of antibiotics with those who did not. Additional analysis was performed for the subgroup of patients with a body mass index (BMI) ≥30 kg/m2. The 2010 to 2021 PearlDiver Mariner data set was reviewed to identify reduction mammaplasty patients. Patients were confirmed to have received perioperative antibiotics. Postoperative antibiotic use was determined based on the presence of postoperative prescriptions, and 1:1 matching was performed for those with and without postoperative antibiotics based on age and the Elixhauser Comorbidity Index. Rates of SSI, emergency department (ED) visits, and readmissions for the 90 days following surgery were recorded and compared. A subgroup analysis was performed on patients with a BMI of ≥30 kg/m2. Among patients who were confirmed to have received perioperative antibiotics, 2230 patients who also received postoperative antibiotics were identified and matched to 2230 patients who did not. Rates of SSI, ED visits, and readmission were not statistically different. A total of 218 obese patients were identified from this group and matched. Rates of SSI, ED visits, and readmission were not statistically different. In the current study, no difference in SSI rates between patients who received postoperative antibiotics and those who did not was found. These observations were corroborated in the obese population. These data may assist surgeons when considering postoperative antibiotics following reduction mammaplasty.

Healthcare-associated infections in Dutch hospitals during the COVID-19 pandemic

BackgroundDuring the COVID-19 pandemic hospitals reorganized their resources and delivery of care, which may have affected the number of healthcare-associated infections (HAIs). We aimed to quantify changes in trends in the number of HAIs in Dutch hospitals during the COVID-19 pandemic.MethodsNational surveillance data from 2016 to 2020 on the prevalence of HAIs measured by point prevalence surveys, and the incidence of surgical site infections (SSIs) and catheter-related bloodstream infections (CRBSIs) were used to compare rates between the pre-pandemic (2016–February 2020) and pandemic (March 2020–December 2020) period.ResultsThe total HAI prevalence among hospitalised patients was higher during the pandemic period (7.4%) compared to pre-pandemic period (6.4%), mainly because of an increase in ventilator-associated pneumonia (VAP), gastro-intestinal infections (GIs) and central nervous system (CNS) infections. No differences in SSI rates were observed during the pandemic, except for a decrease after colorectal surgeries (6.3% (95%-CI 6.0–6.6%) pre-pandemic versus 4.4% (95%-CI 3.9–5.0%) pandemic). The observed CRBSI incidence in the pandemic period (4.0/1,000 CVC days (95%-CI 3.2–4.9)) was significantly higher than predicted based on pre-pandemic trends (1.4/1000 (95%-CI 1.0–2.1)), and was increased in both COVID-19 patients and non-COVID-19 patients at the intensive care unit (ICU).ConclusionsRates of CRBSIs, VAPs, GIs and CNS infections among hospitalised patients increased during the first year of the pandemic. Higher CRBSI rates were observed in both COVID-19 and non-COVID-19 ICU population. The full scope and influencing factors of the pandemic on HAIs needs to be studied in further detail.

Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study.

Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA). We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19 years old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists. Of the 11 878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no-BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (P < .01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no-BLA procedures with beta-lactam AMP (1.6%). Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that the choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association between non-beta-lactam AMP and SSI in children.

Overview of Rate and Risk Factors of Surgical Site Infection in a Tertiary Hospital in Liberia: A Prospective Cohort Study.

Surgical site infection (SSI) is accountable for a third of postoperative deaths and for 8% of all deaths due to hospital-acquired infections. There is a wide disparity in the incidence and burden of SSI in low and high-income countries. To assess the rates and risk factors of SSI in a tertiary hospital in a resource-limited sub-Saharan African country and generate institutional baseline data for future monitoring and interventions. This was a descriptive prospective cohort study done at John F Kennedy Memorial Hospital, a tertiary hospital in Monrovia, Liberia, from October 18 to December 18, 2021. Consecutive participants, including children and adults that had surgical operations within the study period, were recruited. Criteria for diagnosis of SSI were as defined by the Centre for Disease Control (1999). Data were collected on the demography of the participants, type of surgery done, presence of SSI, comorbidities, and risk factors for SSI. Of the 111 patients analyzed, thirty-two patients had SSI giving a hospital incident rate of 28.8%. This comprises superficial SSI (22/31; 71.0%), deep SSI (6/31; 19.4%), and organ/space SSI (3/31; 9.7%). Twelve out of 42 females (28.6%) and 20 of 69 males (29.0%) had SSI. There is no statistically significant difference in gender SSI rate (P = 0.963). SSI occurred more in dirty wounds (13/23; 56.5%), compared to contaminated wounds (6/11, 54.6%), clean contaminated (7/22; 31.8%), and clean wounds (6/55, 10.9%). There is a statistical difference in the rate of SSI among the wound classes (P = 0.001). The infection rate is also more in emergency surgeries (18/39, 46.2%) compared to elective surgeries (14/72, 19.4%), and it is significant (P = 0.003). Statistically, there was no significant difference between the two skin preparation agents used (P = 0.351). The abdomen was the most common site of surgical incision and had the highest rate of SSI (24/79; 30.4%) (P = 0.045). There was no statistical difference in SSI rate between those whose hairs were removed in the ward or in the theatre (P = 0.114); length of incision (P = 0.297), or duration of surgery (P = 0.715) (see table for classification and rates). The SSI rate in our study is high at 28.8%. Abdominal surgeries, emergencies, and wound class accounted for the majority of the SSIs. The baseline data will be useful in developing infection control strategies.

Continuous vs. interrupted subcutaneous suturing following cesarean section: a randomized controlled trial

To assess the preferable technique of subcutaneous suturing during cesarean delivery (CD) and risk of surgical site infection. This is a randomized controlled trial, conducted in a single tertiary medical center between January 2020 and July 2022. Women undergoing elective CD, with a subcutaneous tissue layer of >2 cm were eligible for recruitment. In alignment with the ERAS guideline, patients were randomized to either 2-0 vicryl, continuous subcutaneous tissue closure (c-STC) or interrupted 2-0 vicryl subcutaneous tissue closure (i-STC). Absorbable clips were used for skin. The primary outcome was reported surgical site infection (SSI) within the first 30 days after birth. Secondary outcomes included re-admission rate within 6 weeks postpartum due to SSI, postoperative febrile morbidity, antibiotic use for SSI, CD-to-SSI time interval, rate of bacteremia/sepsis, post-op duration of hospitalization and pain assessed using a visual analogue scale. Sample size was calculated based on a retrospective study performed at our center that showed a 40% difference in rates of SSI between continuous and interrupted subcutaneous tissue closure. To decrease rates of SSI by 40% we calculated we would require 600 patients in each group. The final analysis included 1238 women of whom 607 patients in the c-STC group and 631 patients in the i-STC group. There were no differences in baseline medical and obstetric parameters (table 1). The rate of SSI was significantly lower following i-STC compared to c-STC (2.4% vs. 3.8%, P=0.038). Accordingly, secondary outcomes including re-admission rates (0.8% vs. 1.5%, P=0.014), post-operative febrile morbidity (3% vs. 4.3%, P=0.029), and need for antibiotic treatment (2.7% vs. 4.1%, P=0.041) were significantly lower following i-STC. There were no additional significant differences between the outcomes of both groups (table 2). Our findings suggest that interrupted subcutaneous suturing technique during CD yields a lower rate of surgical site infections and related outcomes compared to subcutaneous continuous suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Broad vs Narrow Spectrum Antibiotics in Common Bile Duct Stones: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Study.

Antimicrobial guidance for common bile duct stones during the perioperative period is limited. We sought to examine the effect of broad-spectrum (BS) vs narrow-spectrum (NS) antibiotics on surgical site infections (SSIs) in patients with common bile duct stones undergoing same-admission cholecystectomy. We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same-admission cholecystectomy for choledocholithiasis and/or acute biliary pancreatitis between 2016 and 2019. We excluded patients with cholangitis, perforated cholecystitis, and nonbiliary infections on admission. Patients were divided based on receipt of BS or NS antibiotics. Our primary outcome was the incidence of SSIs, and secondary outcomes included hospital length of stay, acute kidney injury (AKI), and 30-day readmission for SSI. The cohort had 891 patients: 51.7% (n= 461) received BS antibiotics and 48.3% (n = 430) received NS antibiotics. Overall antibiotic duration was longer in the BS group than in the NS group (6 vs 4 d, p = 0.01); however, there was no difference in rates of SSI (0.9% vs 0.5%, p = 0.7) or 30-day readmission for SSI (1.1% vs 1.2%, p = 1.0). Hospital length of stay was significantly longer in the BS group (p < 0.001) as were rates of AKI (5% vs 1.4%, p = 0.001). On multivariable regression, BS antibiotic use was a risk factor for AKI (adjusted odds ratio 2.8, 95% CI 1.16 to 7.82, p = 0.02). The incidence of SSI and 30-day readmission for SSI was similar between antibiotic groups. However, BS antibiotic use was associated with a longer hospitalization and greater likelihood of AKI.

Preoperative Surgical Site Hair Removal for Elective Abdominal Surgery: Does It Have Impact on Surgical Site Infection.

Introduction Postoperative surgical site infection (SSI) forms the major burden of nosocomial infections in surgical patients. There is prevalent practice of surgical site hair shaving as a part of preoperative preparation. There is uncertainty regarding the benefit versus harm of shaving for SSIs. Hairs at surgical sites are removed prior to surgery most often by shaving. We performed this study to look for what impact preoperative hair removal by shaving has on postoperative SSI. Methods We performed prospective comparative cohort study in patients undergoing elective abdominal surgeries. We included clean and clean-contaminated surgeries in immunocompetent patients of which half were shaved and other half not shaved prior to surgery. Other confounding factors like skin cleaning, aseptic technique of surgery, antibiotic prophylaxis and treatment, and postoperative wound care were as per care. Patients were assessed for presence and grade of SSI postoperatively on day 7, 14, and 30. Results were analyzed statistically using chi-square and Fischer's exact tests for significance in entire sample as well as in demographic subgroups. Results Overall SSI rate was 11.42%. There was no statistically significant difference in SSI rates between patients who underwent preoperative surgical site hair removal by shaving (232) and who did not have shaving (232) on all the three different assessment timelines in postoperative period, namely, day 7, 14, and 30. Although the absolute number of patients who had SSI was more in those who underwent preoperative surgical site hair removal by shaving, the difference was not statistically significant ( p > 0.05). But on subgroup analysis patients with clean-contaminated surgeries ( p = 0.037) and patients with surgeries lasting for less than 2 hours (Fischer's exact = 0.034) had significantly higher SSI in the shaved group compared with unshaved on day 14. Conclusion As per our results, preoperative shaving did not significantly increase overall SSI except in subgroup of clean-contaminated surgeries and in surgeries of less than 2 hours' duration. So especially in these patients avoiding preoperative surgical site hair shaving may be used as one of the infection control measures.

Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials

WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65-1·06]; p=0·21, I2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74-1·09]; p=0·29, I2=36·4%). Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. National Institute for Health Research (NIHR) Global Health Research Unit.

Evaluation of factors associated with surgical site infection in equine proximal interphalangeal joint arthrodesis: 54 cases (2010-2019).

BackgroundThe frequency of surgical site infection (SSI) following orthopaedic implant placement in horses has been reported but not compared with respect to specific antibiotic protocols administered.ObjectivesTo determine factors associated with SSI in horses undergoing proximal interphalangeal joint (PIPJ) arthrodesis including perioperative antibiotic protocols.MethodsRecords were evaluated (2010–2019), and horses undergoing PIPJ arthrodesis were identified. Patient signalment, supervising surgeon, reason for surgery, limb, implants placed, anaesthetic time, duration casting/coaptation postoperatively, antibiotic regimen and incidence/onset SSI were recorded. Bayesian and frequentist logistic regressions were used to estimate the contribution of covariates to infection occurrence.ResultsFifty‐four PIPJ arthrodeses were performed. SSI occurred in 2/54 (3.7%) on day 15,30. Arthrodesis was performed most commonly for osteoarthritis (33/54, 61.1%), fracture (11/54, 20.4%), and subluxation (5/54, 9.3%). Perioperative systemic antibiotics were administered 1–3 days (15/54, 27.8%) or > 3 days (39/54, 72.2%). Antibiotic protocols included cefazolin/gentamicin (20/54, 37%), cefazolin/gentamicin/doxycycline (14/54, 25.9%) and potassium penicillin/gentamicin (10/54, 18.5%). Regional limb perfusion was performed preoperatively 31/54 (57.4%) and postoperatively 7/54 (13%). Survival to dismissal was 98.1% (53/54 horses) with one horse euthanized due to support limb laminitis. No association was identified between antibiotic selection or duration (1–3 vs. > 3 days), pre‐operative regional antibiotic perfusion, intraoperative antibiotic lavage or anaesthetic time (< or > 3 h) and SSI; however, modelling was complicated by quasi‐complete or complete separation of the data. Bayesian analysis (but not frequentist analysis) indicated an association between post‐operative regional antibiotic perfusion and SSI. Limitations include the retrospective nature of data collection and the low rate of infection overall.ConclusionsThe prevalence of SSI in this population was lower than that in previous reports of equine orthopaedic internal fixation. There was no difference in SSI rate in cases administered systemic antibiotics for 1–3 days or >3 days, or for those horses that did or did not receive preoperative regional antibiotic perfusion.

Open and Closed Approaches to Skin Closure After Nonelective Open Colorectal Operations.

Optimal wound management strategies to reduce surgical site infections (SSIs) in nonelective open colorectal surgery (NOCS) remain controversial and variable. Our aim is to describe SSI and other 30-day outcome measures among patients with varying wound management techniques undergoing NOCS. All NOCS patients were extracted from the 2016 to 2018 ACS-NSQIP database. Outcomes of patients managed with all layers closed (ALC) were compared to patients managed with skin open (SO), using propensity score matching (PSM) to control for significant confounding risk factors for SSI. A total of 40,820 patients were included; 4622 patients managed with SO and 36,198 managed with ALC. Patients in the SO group were more likely to have a history of hypertension, renal failure, chronic obstructive pulmonary disease, smoking, obesity, and sepsis on presentation (P < .001). After PSM, no differences in risk factors remained; 4622 and 4344 patients were included in the SO and ALC cohorts, respectively. While ALC patients experienced a higher rate of superficial SSI (1.4% vs 7.3%, P < .001) and any wound complications (6.8% vs 10.8%, P < .001), the SO group had higher wound dehiscence (4.4% vs 2.8%, P < .001). There were no significant differences in deep wound infection. The SO group had longer average length of stay (14.7 vs 13.1days, P < .001), higher non-wound-related complications, discharge to SNF, and in-hospital mortality. Significant differences in SSI rates among NOCS patients with differing wound management techniques were observed. More notably, other important quality measures, such as length of stay, disposition, mortality, and non-wound-related complications were also significantly impacted by wound management strategy.

The role of skin antisepsis in upper extremity surgery to reduce surgical site infection: a comparison between single and triple regimens

Purpose: No consensus exits regarding preoperative skin antisepsis for upper extremity surgery. We aimed to determine whether the use of povidone-iodine only (single regimen) instead of povidone-iodine and alcohol-chlorhexidine (triple regimen) resulted in an increased rate of surgical site infection (SSI), and to detect any associated factors that increased the infection risk.Methods: A cross-sectional, retrospective review of medical records was conducted for patients who underwent upper extremity surgery from March 2020 to February 2021. Either the single or triple regimen was used for preoperative skin antisepsis. The rate of SSI was compared based on a marked elevation of C-reactive protein (CRP) at 2 weeks after surgery, superficial SSI, and deep SSI. Logistic regression analysis was performed to identify factors associated with SSI among the evaluated parameters.Results: Among 175 patients (male, 81 and female, 94), the single regimen was used in 78 patients (44.6%) and the triple regimen in 97 patients (55.4%). The single regimen (odds ratio [OR], 2.425; 95% confidence interval [CI], 1.040–5.655) and a surgical procedure using a metal implant (OR, 3.602; 95% CI, 1.184–10.953) were significantly associated with a marked CRP elevation at 2 weeks. However, there was no differencein SSI rates between the single and triple regimens. Diabetes mellitus (OR, 6.636; 95% CI, 1.259–34.969) was the only factor significantly associated with superficial SSI through logistic regression analysis.Conclusion: Our study suggests that the single regimen resulted in a longer CRP elevation than the triple regimen, but was similarly effective in preventing SSI for upper extremity surgery.

Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures.

Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery. In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates. The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15). This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

The Role of Vancomycin Powder During Spinal Cord Stimulator Implantation: A Case Series and Review of the Literature

We examined the role of intrawound vancomycin powder as prophylaxis against postoperative surgical site infection (SSI) after spinal cord stimulator (SCS) implantation. We performed a retrospective analysis of 153 consecutive patients who had undergone permanent SCS implantation surgery via open laminectomy between 2014 and 2020. We queried the patients' medical records for patient age, sex, relevant medical history, and whether intrawound vancomycin had been administered. We compared the rates of SSI (primary outcome) and seroma (secondary outcome) within 3 months after surgery between the vancomycin and no-vancomycin groups. Finally, we conducted multivariable logistic regression analyses to identify independent predictors of postoperative SSI or seroma. Of the 153 patients, 59% were women, and the average age was 65.4 years. Overall, 3 patients (2%) had developed an SSI: 2 (methicillin-resistant Staphylococcus aureus, Klebsiella) in the vancomycin group and 1 (methicillin-sensitive Staphylococcus aureus) in the no-vancomycin group. This difference in SSI rate between the 2 groups was insignificant (P= 0.73). Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P= 0.04). Multivariate logistic regression failed to identify any perioperative characteristics as independent predictors of postoperative SSI or seroma. Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation. We failed to draw any definitive conclusions regarding its efficacy, despite referencing the largest single case series of SCS implantation to date.

Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. Level III.

Intrawound vancomycin application after spinal surgery: a propensity score-matched cohort analysis.

Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates. The authors performed a retrospective, vancomycin exposure-matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort. A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance. The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram-negative bacteria and increase rates of wound disruption.